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Psoriasis - Hair and Scalp
See also in: Overview,Anogenital,Nail and Distal Digit
Other Resources UpToDate PubMed

Psoriasis - Hair and Scalp

See also in: Overview,Anogenital,Nail and Distal Digit
Contributors: Jeffrey M. Cohen MD, Susan Burgin MD, Belinda Tan MD, PhD, Mary Gail Mercurio MD, Jeffrey D. Bernhard MD, Lowell A. Goldsmith MD, MPH
Other Resources UpToDate PubMed

Synopsis

Psoriasis is a chronic, intermittently relapsing inflammatory disease characterized by sharply demarcated erythematous, silvery, scaly plaques most often seen on the scalp, elbows, and knees. Additional sites of involvement include the nails, hands, feet, and trunk. Psoriasis affects about 2% of the world's population and can develop at any age, in both sexes, and in all races, although it occurs most frequently in individuals of Northern European descent. Psoriasis is commonly categorized as mild (covers less than 3% of the body), moderate (3%-10%), or severe (over 10%).

Psoriasis is a polygenic disease (several psoriasis susceptibility genes have been identified over recent years). Certain individuals with genetic susceptibility develop a psoriatic phenotype after exposure to environmental triggers such as infection, medications, and medical comorbidities, among others. Aberrant T-cell function and keratinocyte responses are believed to be major culprits in the pathogenesis of psoriasis.

There are several variants of the disease, and variants can coexist in the same individual.

Chronic plaque psoriasis is most common, and disease burden can range from 1%-2% (mild disease) to greater than 90% (erythrodermic psoriasis) of the total body surface area (BSA). Typical findings include well-demarcated circular, oval, or polycyclic erythematous plaques with micaceous scale that are often symmetric in distribution. The scalp, elbows, and knees are commonly involved. Lesions are often pruritic and resolve with postinflammatory hyper- or hypopigmentation. Scarring is not a feature of resolution. During exacerbations, erythematous papules usually surround existing plaques, and a ring of intense erythema surrounds the plaques. During resolution, plaques will often have a decreased amount of scale and central clearing, creating annular psoriatic lesions. Lesions can last from months to years in the same location.

Inverse psoriasis occurs in intertriginous areas of the body, such as the axillae, groin, genitals, and submammary area. When psoriasis involves areas of the face other than the hairline, eyebrows, and beard, it is usually an indication of more severe disease. Seborrheic dermatitis can co-exist with psoriasis on the face and scalp (sometimes referred to as "sebopsoriasis").

Other variants include:
  • Psoriatic arthritis – Up to 50% of psoriatic patients may have erosive psoriatic arthritis. Psoriatic arthritis is more common among individuals with nail and scalp psoriasis. Rarely, psoriatic arthritis has been reported to develop prior to the cutaneous findings of psoriasis.
  • Guttate psoriasis – An acute generalized eruption of small, discrete, raindrop-like papules with fine scale. This may occur 2-3 weeks after an upper respiratory infection and is most common in children.
  • Erythrodermic psoriasis – An uncommon but potentially life-threatening acute complication of psoriasis wherein large red patches with desquamation cover most of the body surface.
  • Pustular psoriasis – An uncommon, sometimes severe, variant characterized by widespread erythematous, sterile pustules.
  • Acrodermatitis continua of Hallopeau – An uncommon variant of pustular psoriasis affecting the hands and feet.
  • Inverse psoriasis – Psoriasis that involves the intertriginous areas including the axillae, inframammary areas, and inguinal folds. The plaques of inverse psoriasis are erythematous and well-demarcated but often lack the classic scale as these body sites are generally moist.
  • Nail psoriasis – The nails of individuals with psoriasis can show several features. The most common are pitting, distal onycholysis, and splinter hemorrhages. Individuals with nail psoriasis are at an increased risk of developing psoriatic arthritis.
Immunocompromised Patient Considerations:
Approximately 50% of women report improvement of disease burden during pregnancy. Pustular psoriasis developing in hypocalcemic women during pregnancy is known as impetigo herpetiformis.

Human immunodeficiency virus (HIV) infection may precipitate or exacerbate psoriasis.

Codes

ICD10CM:
L40.0 – Psoriasis vulgaris

SNOMEDCT:
9014002 – Psoriasis

Look For

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Chronic atopic dermatitis patients are often aware of their atopic history, which commonly starts in childhood. More pruritic than psoriasis. The scalp may be involved with pruritic pink plaques with thinner scale, erosions, and excoriations.
  • Seborrheic dermatitis – In mild seborrheic dermatitis, dandruff only will be seen. In more developed cases, erythematous plaques with greasy scales are seen on the scalp. Seborrheic dermatitis and psoriasis frequently overlap.
  • Tinea capitis – Scale at leading edge of erythema with central clearing. Broken-off hairs or inflammatory boggy plaques (kerion) may be seen. Perform a KOH (potassium hydroxide) preparation of scales and hair.
  • Contact dermatitis – The scalp is initially spared in a contact dermatitis to a contactant that has been applied to the scalp, such as a shampoo. Initially, this will manifest on the skin around the scalp, and only after repeated exposure will the scalp be affected.
  • Dermatomyositis – Scalp involvement manifests with very pruritic and scaly violaceous erythema.
  • Pityriasis amiantacea – Thick adherent scales surround proximal hair shafts. It may be an isolated finding or it may occur in association with inflammatory conditions. Of these, psoriasis and seborrheic dermatitis are most commonly seen.
  • Secondary syphilis – "Moth-eaten" alopecia without scales is seen. Check rapid plasma reagin (RPR) and evaluate for history of primary chancre and systemic symptoms.
  • Crusted scabies – Most often seen in elderly, immunocompromised, or institutionalized patients. Scalp is typically spared; however, there are anecdotal cases of scalp involvement in immunocompromised individuals.

Best Tests

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Management Pearls

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Therapy

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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References

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Last Reviewed:11/18/2020
Last Updated:07/08/2020
Copyright © 2021 VisualDx®. All rights reserved.
Psoriasis - Hair and Scalp
See also in: Overview,Anogenital,Nail and Distal Digit
Psoriasis : Erythroderma, Extensor distribution, Nail pits, Scalp, Subungual hyperkeratosis, Onycholysis
Clinical image of Psoriasis
Well-demarcated annular scaly papules and plaques with erythema on the back.
Copyright © 2021 VisualDx®. All rights reserved.